What is the proper management of heart failure?

Management of Heart Failure

The proper management of heart failure requires a staged, algorithmic approach centered on four foundational medications—ACE inhibitors (or ARNIs), beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors—titrated to target doses, with diuretics added for fluid management and device therapy considered in appropriate candidates. 1

Staging-Based Treatment Algorithm

Stage A (At Risk, No Structural Disease)

• Aggressively control hypertension with target BP <130/80 mmHg if cardiovascular risk >10% 2
• Treat hyperlipidemia with statins to reduce incident heart failure risk by approximately 50% 3
• Consider ACE inhibitors or ARBs in patients with atherosclerotic disease, diabetes, or hypertension 3, 1
• Mandate smoking cessation and avoid excessive alcohol intake, as tobacco triples heart failure risk 3
• Address obesity and diabetes aggressively, as dysglycemia directly predicts incident heart failure 3

Stage B (Structural Disease, No Symptoms)

• Initiate ACE inhibitor (e.g., enalapril 2.5-5 mg twice daily, uptitrate to 10-20 mg twice daily over 2-4 weeks) 2
• Add beta-blocker and titrate to target doses in all patients with reduced ejection fraction, particularly post-MI 3, 1
• Continue statin therapy to prevent symptomatic heart failure and cardiovascular events 3
• Monitor for intolerance: if ACE inhibitor causes cough or angioedema, switch to ARB; if hypotension or renal insufficiency occurs, consider hydralazine/nitrate combination 3

Stage C (Structural Disease With Current/Prior Symptoms)

Foundation: Four-Pillar Therapy

All patients with HFrEF (LVEF ≤40%) should receive:

1. ACE inhibitor/ARB/ARNI as first-line for mortality reduction 1, 2

   • Titrate to target doses over 2-4 weeks 2
   • If intolerant to ACE inhibitor, use ARB 3
   • Avoid adding ARB to combination of ACE inhibitor plus beta-blocker 3

2. Beta-blocker to reduce mortality and hospitalizations 1, 2

   • Continue during hospitalization unless hemodynamically unstable 2
   • Main reasons for not reaching target: hypotension (45%), fatigue (32%), dyspnea (14%), dizziness (12%), bradycardia (6%) 4

3. Mineralocorticoid receptor antagonist (spironolactone ≤12.5-50 mg daily) 3

   • For patients with NYHA class II-IV and LVEF ≤35% 1
   • Monitor potassium and renal function closely to avoid hyperkalemia 3

4. SGLT2 inhibitor for proven mortality benefit in both HFrEF and HFpEF 1, 2

Symptomatic Management

• Diuretics are essential when fluid overload manifests as pulmonary congestion or peripheral edema 3, 1
• Use cautiously: avoid excessive diuresis that lowers preload excessively and reduces stroke volume 3, 5
• For refractory congestion: combine loop diuretic with thiazide 3
• Teach flexible diuretic regimen based on daily weight monitoring 1

Additional Therapies for Selected Patients

• Hydralazine/isosorbide dinitrate: for ACE inhibitor intolerance due to hypotension or renal insufficiency; particularly beneficial in African Americans 3, 1
• Digoxin: may reduce symptoms and enhance exercise tolerance, especially with atrial fibrillation 1, 2
  • Monitor for toxicity, particularly in renal impairment 1
• Exercise training: improves functional capacity and quality of life in stable NYHA class I-III patients 3, 1

Stage D (Refractory/Advanced Heart Failure)

Clinical Indicators Requiring Advanced Therapies

• Repeated hospitalizations in past 12 months 3
• Persistent NYHA class III-IV despite optimal therapy 3
• Peak VO₂ <14 mL/kg/min or 6-minute walk <300 m 3
• Frequent systolic BP <90 mmHg 3
• Progressive renal/hepatic dysfunction 3
• Inotrope dependence 3

Management Options

• Continuous intravenous inotropic support as bridge to mechanical circulatory support or transplantation 3
• Consider cardiac transplantation for eligible patients persisting in NYHA IV despite optimal treatment 3
• Mechanical circulatory support for eligible candidates 3, 1
• Palliative care with opiates for symptom relief in terminal patients 3

Device Therapy

• Implantable cardioverter-defibrillator (ICD): for primary prevention in patients with LVEF ≤30-35%, NYHA class II-III on optimal medical therapy ≥3 months, life expectancy >1 year 2
• Cardiac resynchronization therapy (CRT): indicated with LVEF ≤35%, sinus rhythm, NYHA class II-IV, QRS ≥150 ms with left bundle branch block 2

Management of Acute Decompensation

• Administer IV loop diuretics at doses equal to or exceeding chronic oral daily dose within 1 hour of presentation 2
• Continue ACE inhibitors and beta-blockers unless hemodynamically unstable 2
• Monitor continuously for at least 24 hours: heart rate, rhythm, blood pressure, oxygen saturation 3
• Schedule early follow-up within 7-14 days and telephone follow-up within 3 days of discharge 3
• First follow-up within 10 days of discharge for optimal outcomes 1

Special Populations: Diastolic Heart Failure (HFpEF)

Evidence for diastolic dysfunction treatment is limited (Level C) 3

• Diuretics cautiously for fluid overload—avoid excessive diuresis as diastolic dysfunction is highly preload-dependent 5
• ACE inhibitors to improve relaxation, reduce hypertrophy, control hypertension 3, 5
• Beta-blockers to lower heart rate and increase diastolic filling period 3, 5
• Verapamil-type calcium antagonists may improve function, particularly in hypertrophic cardiomyopathy 3, 5
• SGLT2 inhibitors based on recent evidence 5

Atrial Fibrillation in HFpEF

• Rate control is mandatory in permanent atrial fibrillation 3
• Digitalis glycosides are first choice for symptomatic patients 3, 5
• Consider electrical cardioversion for persistent atrial fibrillation, though success depends on duration and left atrial size 3
• Amiodarone for conversion to sinus rhythm if rhythm control pursued 1

Lifestyle Modifications

• Restrict sodium to <2-3 g/day and measure weight daily at same time 2
• Fluid restriction benefit is uncertain in advanced heart failure with hyponatremia 3
• Smoking cessation mandatory with nicotine replacement therapies if needed 3
• Avoid excessive alcohol intake 3
• Regular physical activity in stable patients to prevent muscle deconditioning 3

Monitoring Requirements

• At each visit: symptoms, weight, blood pressure, heart rate, volume status, renal function, electrolytes 2
• Natriuretic peptides (BNP or NT-proBNP) at baseline; consider serial measurements to guide therapy 2
• Renal function and electrolytes regularly, especially after dose changes 1

Critical Pitfalls to Avoid

• Never use calcium channel blockers as treatment for heart failure 3
• Never use long-term intermittent positive inotropic therapy 3
• Avoid routine nutritional supplements (coenzyme Q10, carnitine) or hormonal therapies 3
• Do not add ARB to ACE inhibitor plus beta-blocker combination 3
• Never over-diurese in diastolic dysfunction—can precipitate hypotension and reduced cardiac output 5
• Avoid tachycardia in diastolic dysfunction—atrial contribution to filling is critical 5

Multidisciplinary Approach

• Implement disease-management programs for high-risk patients to improve quality of life, reduce readmissions, and decrease costs 1, 2
• Patient education: explain heart failure mechanism, symptom recognition, self-weighing, medication adherence, when to seek help 3
• Team-based approach with structured follow-up and clear transitional care plans 1